Book Review Continued: Crazy Like Us

Yesterday I began a review of Ethan Watters’ Crazy Like Us. I’ll try to conclude today.

Watters’ initial chapter, which concerns the spread of anorexia in Hong Kong, failed to convince me, not, I think because it’s poorly researched, but because the book has a cumulative effect. As I worked my way through his case studies — PTSD in Sri Lanka following the tsunami, schizophrenia in Zanzibar, and depression in Japan — I found myself coming to accept his argument, bold as it is, for two reasons. First, it’s well-argued and researched; second, it squares neatly with my own experience in the mental health system. In this review I’ll often refer to the latter, since I think it puts me in a unique position to evaluate Watters’ work.

Each chapter details a truly appalling abuse of professional and economic power. It’s not an exaggeration to say that his description of hundreds of slavering therapists and researchers descending on post-tsunami Sri Lanka shocked me. I’m familiar with psychiatric and therapeutic abuses, but I had no idea that they exist on a huge international scale; I’ve always said you can never be cynical enough about Big Pharma, and clearly I haven’t been.

Narrative and anecdote appeal to me, and the details the author furnishes dovetailed with my own adventures in diagnosis. For instance, I’ve always felt that Post-Traumatic Stress Disorder has many of the hallmarks of a socially transmitted moral panic. This is the case even though I displayed classic symptoms for roughly seven years after having been raped. I’ve felt skeptical about my own diagnosis because, eerily, all but one of my psychiatrists has interrogated me about the possibility that I’ve suffered childhood sexual assault, and only reluctantly accepted that I haven’t. Typically they dismiss the actual rape, preferring to spend session after session hunting the chimera of incestuous gropings.

It’s long been established, most notably in the New York Review of Books, that supposedly therapeutic techniques popular in the 80’s and 90’s convinced countless patients that they’d suffered everything from incest to ritual satanic abuse; the diagnosis of PTSD grew in part out of just these techniques. I’ve witnessed these psychological abuses myself. In a therapy group I attended in the early 90’s, a woman became wholly convinced that a beloved uncle had fondled her repeatedly even though she couldn’t remember a single incident. Far from acting intentionally or out of spite, the victim was horrified at the very idea that her uncle, who had just died, could have done such a thing. Though she’d discovered the abuse during a highly suspect group process of “rebirthing,” during the months that I belonged to the group, she never doubted that it had happened. It saddens me deeply to think of the damage that these almost certainly manufactured memories must have caused her and her family.

Following that experience, I’m not at all surprised that self-styled and mostly well-meaning American PTSD counselors imposed their own model of trauma on Sri Lankans, undermining the more suitable style of coping that they learned from their own culture. Article after article in The Times and elsewhere attests to the international spread of PTSD; the consequences may be debatable, but the fact of its growth is not.

The third and fourth chapters, which concern schizophrenia in Zanzibar and “The Mega-Marketing of Depression in Japan” deal with diseases that Western medicine considers to be purely biological. Watters demonstrates convincingly that though the most devastating mental illnesses transcend culture, their expression and treatment vary to an extent that took me by surprise. When you think about it, though, it makes sense that sufferers in different cultures should experience widely different psychotic delusions, and that their families and society should understand them as, say, spirit possession rather than the expression of a broken brain. Western psychiatric history holds that the former belief is much more stigmatizing than the latter, but Watters demonstrates through anecdote and research studies that the opposite is true; people who attribute mental illnesses to genetic causes fear and shun the mentally ill more than their counterparts who hold to earlier models.

Given our perverse health care system, our recent romance with a medical model of mental functioning condemns many people to lives that ought to appall us. As David A. Karp demonstrates in The Burden of Sympathy, which I reviewed in this space, American families with mentally ill members receive no meaningful social or financial help from either public or private sources. Without extensive family support, seriously mentally ill people in America risk ending up either homeless or imprisoned. In my case, with my family’s support, I earned a Ph.D., hold a demanding job, and own a home (and, no, they didn’t buy the latter for me); I would not have been able to house myself or hold a job for all these years without their help.

You may ask, What about psych drugs? Surely the benefits of American medical treatment outweigh the risks of our fragmented culture, at least for those who can afford it. More than one shrink has told me with a mystified air that the prognosis of Third World mental patients is much better than that of their most privileged American peers. In other words, even if it’s factually true that genetics and brain chemistry cause schizophrenia and bipolar disorder, we’re unable to turn our scientific understanding into treatments that work.

More on that later, though. I’ll return to the issues Watters raises in Crazy Like Us tomorrow.

Briefly noted: The longest hypomanic stretch in my life may be ending. Every day for the last 10 days I’ve been dreading the return of my depression and hoping that I’ve finally recovered the real Dr. RandR. I wish so much that I could shed the drooping self that irks me so and claim my feisty, temperamental pre-Klonopin existence. I am trying to tamp down hope, since I know perfectly well that mania is marked by a sense that you’ve morphed into your better, true self. In the meantime, I’m savoring this thrilling clarity of thought and sense of the incandescent web that interconnects words.

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Your review of Ethan Watters book Crazy Like us is spot on It is well reasoned and accurately starts with a discussion of understanding the importance of “socially constructed” symptom patterns This helps explain not only cultural variations but also why the presentation and content of symptoms varies with what is going on in the social millieu of a patient at a particular historical time. It is a very tough concept to get across without moving toward simplistic reductionism and I thought it was done very ably.

I also thought your acceptance of the anecdotal “incident reports” that Watters uses to make his points was commendable and you correctly point out that his argument grows on you as you read each report cumulatively. People will reject his ideas though because they lack hard data but cultural psychiatry understanding must rely on less replicable truths.

Instead of discontinuing the review I thought I would like to hear even more from you (if you are able to cut through the depressive mood trend that you have observed).>

Thanks so much for your comments — I agree that I should have continued with my review of Watters’ book. I know that many of my readers will be skeptical of his argument, and I’d like to persuade them to at least take a look. Unfortunately I’m involved in an intensive outpatient program right now that’s taking much of the free time that I would normally devote to blogging. Your comment makes me think that it would be worth returning to Watters’ book when I return, however.

Thanks for the reflections on Watters’ book. Haven’t read it yet, but the thesis is certainly interesting. I recall very well the scandalous McMartin preschool case from the mid-eighties, though that’s a particularly outrageous example of what Watters seems to be addressing: lives were ruined by an overzealous application of pseudo-psychoanalytic theories, and the press and the public really got caught up in the foolishness. Stuff like this just seems to recur from one decade to the next, and we learn nothing from it. The only caveat here is that sometimes authors are quick to dismiss the very idea that meds for depression might be necessary for anyone at all, and in that sense I think they go too far. But I presume that isn’t the sort of thing Watters is arguing.

Revolt and Resignation

In his collection of essays On Aging, Holocaust survivor Jean Amery said that one must meet the phenomenon of aging -- inevitable yet terrifying -- with both revolt and resignation. So it is with mental illness. To deny that I will always be manic-depressive would be true madness; at the same time, I must revolt against my condition, rejecting the idea that it defines and limits me.